Community Perception Regarding Childhood Vaccinations and Its Implications for Effectiveness: A Qualitative Study in Rural Burkina Faso

The aim of this study is to determine the reasons related to complete and incomplete immunisation coverage among children in the Nouna Health District (NHD), 300 km from the capital Ouagadougou in northwestern Burkina Faso, with a focus on the communities' perception and the provision of immunisation services. Specific study objectives are to understand perceptions of mothers and health workers regarding the Expanded Program on Immunization (EPI), to identify factors that influence immunisation coverage, and to make recommendations on how to improve the vaccination programme (EPI).

Although the EPI has contributed significantly to global reductions in childhood morbidity and mortality, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) estimate that 1.5 million children worldwide continue to die from vaccine-preventable diseases every year because of inadequate vaccination coverage, mainly in Sub-Saharan Africa (SSA) and South-East Asia. According to the researchers, when programmes with the goal to increase immunisation coverage are developed and implemented, knowledge, awareness, attitudes, beliefs, and circumstances of the concerned populations are often ignored and poorly documented. "Special emphasis should thus be placed on listening to concerns and understanding perceptions of the community and parents regarding reasons why some children are incompletely vaccinated or not vaccinated at all."

In that context, the descriptive qualitative study was conducted in the Nouna Health and Demographic Surveillance System (HDSS) area, rural Burkina Faso, from March to April 2014. The researchers employed a combination of 29 in-depth interviews and four focus group discussions (FGDs) including health workers responsible for performing vaccination, "godmothers" ("doctoro mousso", community women leaders), community health workers (CHW) who disseminate information about immunisation schedule in their community, traditional healers who provide traditional health care measures to children, and mothers of children less than three years. A thematic analysis was performed.

Results are shared according to these topics (with quotations from FGD participants used throughout to illustrate findings):

• The organisation of the vaccination programme in NHD - One finding: CHWs have an important role in the implementation of immunisation strategies. They are responsible for informing, sensitising, and mobilising people. They go door to door asking women to meet the appointment set by the health worker.
• The different vaccination strategies used in rural and urban areas to improve immunisation coverage - One finding: In the rural areas, everybody knows each other, which makes looking for absent mothers and children in the village easier. The way the vaccination sessions are organised in the rural areas puts a kind of social pressure on the women, and the system of looking for absent mothers in the village hence leads to better coverage. That is, there was better social mobilisation in the rural areas as compared to the urban area.
• Community knowledge and perceptions towards routine childhood vaccination - One finding: Most mothers know the EPI target diseases (those most reported include poliomyelitis, measles, yellow fever, and meningitis) and the importance of immunising their children. However, the great majority of informants reported that mothers don't know the vaccination schedule. In most cases, participants get information on immunization from their health workers at peripheral health centres (CSPS), from CHWs and godmothers, and through the radio. Other sources of information on immunisation included mosques and churches. People at the community level who play a significant role here regarding vaccinations include religious leaders, griots (traditional musicians and storytellers, societal leaders, and guards of the oral tradition), and village administrative officers.
• Reasons for incomplete or delayed vaccination - One finding: There is awareness that some children are incompletely vaccinated. Mentioned reasons for that were migration, mothers being busy with their work, the practice of not opening vaccine vials unless a critical number of children are present, poor interaction between women and health workers during immunisation sessions, potential adverse events associated with vaccination, geographic inaccessibility during rainy season, lack of information (e.g., due to illiteracy), and misinformation or rumours about vaccinations.

Among the recommendations to improve coverage: Reduce missed opportunities by creating collaboration among health facilities during the vaccination sessions. Furthermore, with a system of CHWs in place, sensitising mothers and emphasising messages about the benefits of vaccination sessions is important. A special focus should here be placed on the challenge of migration/movement of mothers without the vaccination card. Information and education of mothers about the importance of the card and the possibility and necessity of bringing the card to and getting vaccinations at health facilities elsewhere should be highlighted.

"The study has provided further evidence for the importance of knowledge on community perceptions regarding improvement of childhood vaccination program effectiveness. To achieve the national objective of complete and timely immunization coverage of 80% of eligible children, there is a need to consider the factors identified as barriers to the uptake of immunizations. In particular, there is a need to revise the policy of opening of vials only if a certain number of children is available. Such a change in policy will likely also increase the efficacy of the vaccination schedules due to the positive non-specific effects of childhood immunizations."